Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome from the Department of Health Mr Mike Farrar, the permanent secretary; Professor Cathy Harrison, the senior responsible owner (SRO) for the neighbourhood programme and the Chief Pharmaceutical Officer (CPO); and Mr Gearóid Cassidy, the director of primary care. We have received your paper. I will hand over to you for some introductory remarks.

Mr Mike Farrar (Department of Health): Thank you, Chair, for holding this session, which is timely. We are at the beginning of the implementation of the neighbourhood arrangements, so scrutiny is useful. My opening remarks will cover the "Why?", the "What?" and the "How?", but they will be fairly brief. I am sure that you will get into a conversation with us about them as we move through the meeting.

The "Why?" is obvious. Northern Ireland's spending on health and care had been accelerating, but, as we know, it has flatlined over the past couple of years, even though the Department of Health is still spending over 50% of the Budget. We know that, given that the increasing population of older people uses more healthcare as they get older, continuing to ask for more of Northern Ireland's allocation is not a realistic prospect. We would also be denying resources to education, employment and so on, which are wider determinants of health. The solution therefore has to be different from before. To cut to the chase, we have to focus more on demand and on managing people's care earlier. Early interventions also have to be standardised and evidence-based in order to diagnose the problem and manage people away from the more expensive elements of care in our hospitals. That would have the added advantage of freeing up hospitals for the people who need that care.

The "Why?" is clear: it is about focusing on moving care earlier in the pathway. We need a structure to enable that to happen. As with other systems, we have created a vehicle by which we can have a governance arrangement for all the resources that are outwith hospital care. We have to manage those resources collectively, because, outside of hospitals, services tend to fragment. We have community trusts and some social care services that are commissioned. We also have general practice, community pharmacy and the really important contribution of the voluntary sector. We have a lot of the assets in place, but they tend to be uncoordinated. As a result, we tend not to get value when we spend money. Moreover, we do not really have an easy platform for shifting the money that we are currently spending inappropriately on hospitals so that it is governed and overseen by a structure in the community.

The "What?" is that, under the neighbourhood approach, we propose to create 17 integrated neighbourhood teams (INTs). Those teams will represent the big five areas but with stakeholders connected to them, including the trusts' community services and, indeed, some of their secondary services that, we believe, should be community-focused. Those include general practitioners, community pharmacists, the voluntary sector and local government as the big players, but the teams would also, for example, have the ability to connect with independent care providers in order to link the whole range of services. They will not be committees, and I want to make that clear from the word "Go". In the past, we had structures that were committee-like, but the integrated neighbourhood teams will almost be like management boards for the community resource. Coordinating our current resource and increasing it by moving some of the budgets from our hospitals, in which people are being inappropriately treated, so that they are under the direction of the INTs will not only allow us to get the right people into the right places but allow us to manage the demand for some of our more expensive resources. I am sure that we will talk about it later, but we have indicated 2% a year for the next three years as the aspirational shift that we want to make. We genuinely believe that people will get better outcomes from that.

I will give the Committee a concrete example of that so that it is not just conceptual. Look at palliative care. We know that people do not want to be in hospital, and that is also true of older people. People would prefer to be managed in their own home, but a lot of them currently receive care in hospital settings. If they are not receiving palliative care, they are probably deconditioning and at high risk of hospital-acquired infection. Often, we admit people for conditions that had previously been managed. They are thus taking up valuable hospital beds that could be freed up to reduce waiting times for people who want elective care, for example. We know that that is also an issue. The "What?" is therefore to create those structures in each of the 17 areas and give the INTs the ability to direct resource to the best place. That might involve bringing a service out of hospital; commissioning general practice, through putting more money into it, to deliver an alternative; or supporting carers in communities who, if they had more support, could support family members so that they avoid losing their independent living. Integrated neighbourhood teams are therefore at the heart of the neighbourhood model.

I will talk briefly about where we are with that. We have done a bunch of work, and Cathy and Gearóid will be happy to answer questions on the stakeholder engagement that has led us to this point. In effect, we have said that we do not want to start to do it piecemeal. Everybody is now working to identify their integrated neighbourhood team. That is being done using the footprint of GP federations, so we know the geography. We had our first development day last week, with around 140 people, including from representative bodies such as the British Medical Association and Community Pharmacy Northern Ireland (CPNI), questioning the implementation but not the direction of travel and asking us how we can deal with some of their issues as we proceed. We will hold the next two development days by the end of Q1. I very much hope that, at the end of June, we will know the team that is responsible in each of the 17 areas. We have given them older people's care as a priority for this year, because they are the people who are probably not getting the care that they could get. We believe that a neighbourhood approach is fitting for them. That is in development to go live as we speak. I will be happy to return to the Committee later in the year to tell you about some of the outcomes of the work that the integrated neighbourhood teams are doing.

Finally, I would like to say that we are great innovators and the creators of the model, but it is happening pretty much everywhere. Most health systems are trying to implement it. The difference is that we believe that, because we are a small place and have the leadership that we need, we can implement it faster. I am confident that we will be a trailblazer across the NHS in the four nations and will probably be ahead of the others in demonstrating that the neighbourhood approach makes a difference to patient outcomes and financial sustainability. That is where we are.

The Chairperson (Mr McGuigan): Thank you. That was useful. Out of the "Why?", the "What?" and the "How?", we probably all agree on the "Why?". The Committee has some information on the "What?", but we are probably a bit less clear on the "How?". What is the total monetary value of that 2% funding from the trusts?

Mr Farrar: We are working out the baseline of that 2%. Taking all the resources that we have, it will be around £150 million, but some resources are in tertiary care, where we would not expect there to be a shift, while some resources go into other budgets that we run. In the short term, our ambition is that it will be around £40 million to £50 million a year, but I am confident that, over the three-year period, we will be able to show a shift of somewhere between £50 million and £100 million annually.

The Chairperson (Mr McGuigan): OK. How will the Department ensure that the shifting of that money results in new services in the community, as opposed to a repackaging of services?

Mr Farrar: We have said that we would like it to be auditable, with the Northern Ireland Audit Office (NIAO) commenting on what is moving. As I speak, we are working on the definitions of what we would count as part of the shift. If we were to develop palliative care away from hospitals, we would be able to demonstrate that. I will give another example. When I talked to the cardiologists in the Southern Health and Social Care Trust, they said that their service should be a community-based one, as it would be in other parts of the world, that would in-reach to beds and be more proactive, rather than a hospital service outreaching to manage prevention. We have plans for that.

Cathy and Gearóid have been working on guidance for what that will mean in practice, and I will say a bit more about why it needs to be managed carefully. We will monitor the trusts throughout the year in order to demonstrate that the shift has happened. There will be an ongoing monitoring process. We have held off asking the trusts to put together a plan, because, if we were to do that, there would be a risk of their dictating to the partners that are needed in the community what services they are prepared to move. We really want it to be the INTs that put forward the plans on the basis of what they expect to be able to do. It is probably worth reminding members that, as well as being the permanent secretary, I am the chief executive of Health and Social Care (HSC). That means trusts' accountability comes to me, so, if we were to feel that we were experiencing recalcitrance or that we were not moving at pace, there would be a performance route to bring that up.

The reason that we have to be careful about it is this: in an ideal world, I would have an £800 million surplus and be able to fund double running. Unfortunately, however, I am faced with a deficit, so we have to fix the engine while the car is running, and the money for that is being spent by the trusts on employing people. We have to do it in a managed way, which includes consultation with staff and, indeed, the agreement of the clinicians that the pathway is the right one for change. That is why we have said not that it is an absolute target but that it is an ambition that we will monitor against the 2% figure.

The Chairperson (Mr McGuigan): You said, "£800 million": I was going to quiz the Minister about that, because he said in the Chamber two weeks ago that the shortfall was £670 million. Last week, he —

Mr Farrar: I may be wrong.

The Chairperson (Mr McGuigan): — said that it was £700 million, while —

Mr Farrar: He is an optimist, while I am a pessimist.

The Chairperson (Mr McGuigan): — this week, he has said that it was £800 million. It is difficult for the Committee to scrutinise the health budget if, in the space of three weeks, the deficit is said to be £670 million, then £700 million and now £800 million.

Mr Farrar: I will push back on that by saying that I do not have a budget, so what is in or out —.

The Chairperson (Mr McGuigan): Why, then, are you quoting figures?

Mr Farrar: I am quoting figures because I have to plan. In our planning assumptions, we looked at the funding that we need this year that, on the basis of the draft allocations on which the Minister of Finance consulted, we would not have been given. We got non-recurrent support to make last year's pay award, but we have to make a pay award for the year that we are in. We also have as issues the real living wage and employers' National Insurance contributions. There is a raft of things. The reason that there is still a degree of flexibility is that I am waiting for clarification of whether funding for our commitment on elective waiting times, which is about £80 million, is to be ring-fenced in my allocation. You can see how, one way or another, that could be contributed to savings —.

The Chairperson (Mr McGuigan): I was not being flippant.

Mr Farrar: I understand.

The Chairperson (Mr McGuigan): We understand that, like all Departments, the Department of Health is stretched financially. We also understand the importance that the Executive have attached to Health. Given, however, that the Minister has said that the deficit is £670 million one week, £700 million the next week and £800 million the week after that, it is hard for anybody listening to take the figure seriously. I am just making that point.

Mr Farrar: I understand completely, Chair.

The Chairperson (Mr McGuigan): OK. I will return to the neighbourhood model. We are talking about moving care closer to home and saying that there will be a particular focus on older people, with which I will not disagree, because that is appropriate. We have to square that, however, with the fact that our home care service is under extreme pressure and that pressure is growing. The fact that it is under pressure is already putting our health system under strain. You talked about:

to where it should be spent, and home care is a key example of that. How will doing that help the home care sector, which is under extreme pressure, so much so that, this week, we have heard that the independent sector providers may pull out of it? There is a particular problem in rural areas, where people are not getting the care and attention that they need. Given the cost-of-living crisis and all the other external factors, the problem will probably get worse, because fuel costs have gone up. How will shifting the money help a care provider or somebody who works in the sector who may be listening to this discussion with what they do and with the service that they provide to our vulnerable population?

Mr Farrar: The immediate answer is that they will be the beneficiaries of a moving of resources from a hospital focus to a community focus. We have not done that before; instead, we have increased hospital spend over the past 20 or 30 years. The only time in NHS history that we spent more money out of hospital than in hospital as a percentage of new growth was in 2002-05. The neighbourhood model represents a real shift in what we are trying to do. For a lot of people, it is the care factor, not just the biomedical health factor, that they need to see. If the neighbourhood model works in the way that I hope it does, I anticipate being in a situation in which, to give you a good example, the neighbourhood team will have a list of all the people currently in hospital awaiting discharge who are medically fit for discharge, and they will, daily, actively pursue care packages to support their discharge. That resource will be drawn not just from community health services but from community care services and homes.

The Chairperson (Mr McGuigan): Are you saying that care services will get additional money to provide additional —?

Mr Farrar: They will get additional money if the integrated neighbourhood team believes that that is the right thing to do in order to get the better service outcomes that we want to see. It will be at the INT's discretion. There are other issues at stake with independent care homes, such as the cost of the real living wage, with which we are wrestling. The Committee knows that issue well.

A more strategic point to make is that, as with the independent healthcare sector, we have always had a slightly more spot-purchased, non-strategic relationship with the independent care sector. When we spoke to independent care providers recently, we said that we wanted a longer-term strategic relationship with them that was financially viable so that we were much less vulnerable to market shift. Part of our policy, when we have hopefully got over the immediate issues with the real living wage, is to work with the sector on what a strategic partnership looks like when care is funded properly. The truth is, Chair, that, if we do not fund the care element properly, we will drive up costs further for the medical and mental health elements. That is why we want to have that strategic relationship.

The situation is challenging at the moment, because the sector is under pressure. We are doing our best. I absolutely believe, however, that care services will be the beneficiaries of expenditure to support developing care closer to home. That has to be the case. A lot of that will be in the domiciliary space, not necessarily in the care home or residential nursing home space. That was the issue in the South with rural healthcare.

The Chairperson (Mr McGuigan): You referenced palliative care a couple of times. We have members of independent hospices with us today, and we will cover access to palliative care services in the next evidence session. I have cautioned members not to ask questions on the subject until then, but it is important to the conversation on the neighbourhood model as well, given that the Department has referred to it. For the neighbourhood model, what specific role will independent hospices play in the INTs?

Mr Farrar: I will ask Cathy to answer that. From our call for evidence, we had examples showing that people are already working differently in the sector. With end-of-life care, as you know, most people, if they have to die, would prefer to do so at home with family and friends around them.

Most people tell us that that is what they want in their last times. To be able to provide that, we need to have people who are capable of supporting them in their home or, failing that, in specialist services in which they can be cared for should they have particular needs. Doing that will require a combination of community services, which many of the independent hospice providers already provide. Few of them provide just beds. A lot of them also provide outreach, as you will know from your report. We would therefore be increasing their ability to offer a package of support to someone who is approaching the end of their life that involves a blend of support, such as support for individuals who need residential respite care and, in particular, community palliative care support. When we were in the Republic of Ireland recently, we learned that the number of people whom the independent provider was treating in residential facilities was, I think, about 20 out of 590. The others were being treated in community settings.

I do not want to steal anyone's thunder later, but the good news on palliative care is that we are having an active conversation with Macmillan, which is prepared to put in place a social fund in Northern Ireland. That could be worth around £10 million to £12 million and would allow us to double-run a little the development of the service in order to avoid hospital admission for people at the end of their life. That is an area in which we are confident that we can show progress quickly through the neighbourhood model.

I do not know, Cathy, whether you want to add to that. We have examples of where we work well with —.

The Chairperson (Mr McGuigan): Before Cathy comes in, I have questions that she may be able to answer as well. I am still a bit unclear on how, for example, any sector — in this case, independent hospices — will access any of the 2%. The other key component is to ensure that services are equitable across the North so that they are not different depending on where people live. Doing that will mean that they will get a better service.

Cathy, will you address those issues as well?

Professor Cathy Harrison (Department of Health): The approach that we are taking to funding the neighbourhood model is to have a mixed funding model. We are taking that approach because of the position that we are in at the moment. We have some funding that we will ring-fence to support the integrated neighbourhood teams to get up and running. That funding will have to be prioritised from within existing budgets. The 2% is really significant. It sends a really strong message that we are really serious about change and that this is the beginning of long-term change. As Mike expressed, that change will be really considered in the areas in which we want to see it happen.

We also want to avail ourselves of other opportunities, such as investing to save and working with external partners. We were delighted that Macmillan approached us early in our development of the neighbourhood work, because it is supporting neighbourhood approaches across the UK, and we are keen to do so here. We want to use the money really wisely, because we want it to inform long-term change rather than be a short-term project, and we want to work together. The Committee will probably hear more about this in the session on accessing palliative care, but we really need to think about care pathway design, because care pathways are often across the whole system. I led the "Big Discussion" work on palliative care last year, and it became really apparent to me that, without whole-system thinking, we will not see change. There are already excellent areas of practice, so we are keen to use the opportunity that we have with Macmillan — a substantial amount of money is involved — to think about plugging the gaps in our pathway in order to see what impact that might have. Hospices have an important role to play in that.

The Chairperson (Mr McGuigan): OK. I will pick up on that in the next session.

Mrs Dodds: I will preface my remarks by saying that the neighbourhood model is a great idea. I want it to work, and it must work. I have spoken to many people, including GPs and those who work across the community in various sectors — I know that we have representatives from palliative care teams across Northern Ireland with us today — and the people to whom I have spoken tell me that they lack information, direction and guidance. Until we all get that information, direction and guidance, we will still be talking in a vacuum.

You can correct me if I am wrong — I would be happy to be wrong — but, for this to work, the GP contract will have to be settled. We will also have to have an adequate number of care packages in the community. That issue bothers me significantly. The Southern Trust is my local trust. I live 20 minutes from Craigavon Area Hospital. There are 800-odd care packages outstanding. Across Northern Ireland, on 6 May — I checked the numbers for that date — we had over 600 people in hospital who could not leave because no adequate care was available in the community. Not only are we not helping people to stay in the community but we are not getting people out of hospital. Until those significant issues are resolved and until clearer guidance is produced, I am unclear on how everything will work. Perhaps I am being a bit dense, but I have spoken to so many people who say the same thing. We cannot all be unclear. That is my rant over, but I would like you to address that.

People deserve to know how the neighbourhood model will work. If, for example, people are at the end of their life and are receiving palliative care, will they have somebody to help them in their last days? Will they be able to access that help no matter where they live in Northern Ireland? Given that we have five trusts serving a very small population, variation in service is one of the biggest issues. It is a huge problem. We all deserve to know how the model will work. As I said, I am desperate for it to work. Sense tells me that moving people out of expensive hospital beds is the right thing to do, but, as I have said so many times in the Chamber, if we do not then create capacity in the community, we will not be able to do that. We cannot free up emergency departments, so we will continue to have the Royal College of Emergency Medicine (RCEM) coming to the Committee to tell us about excess deaths because of long ED waits. In 2025, there were over 1,000 excess deaths, which the RCEM put down to waits of over 12 hours in EDs. That is a catastrophic situation for our health service to be in.

I would like a bit more information on the budget. I have spoken to a number of trusts. You said that 2% has to be shifted for community care: I may be old and cynical, but I fear that many trusts could already account for 2% on the basis of the community care that they offer. The Southern Trust, for example, has an excellent service providing acute care at home. It expanded its service when other trusts did not. It could easily say that that is part of its 2%. Is the 2% for new things or existing things? That is really important to know. Unless we are firm about the shift from secondary care to primary care, we cannot have that model, because it will not work. We will all be back here next year talking about it again.

I was looking at the roll-out of healthcare hubs in England. Given that all politics is local, I was thinking about Banbridge; for transparency, I live in Banbridge. We have an excellent health and care centre that could be a brilliant model for taking so much out of a hospital and putting it into a local healthcare hub. It is on the site of the old Banbridge Hospital, which closed many years ago. It is a brilliant, brand-new facility that could be one of the healthcare hubs. Sometimes, however, when people are sent to it for an X-ray, there is no one there because of a staffing shortage elsewhere. Staff may have been called back to Craigavon Hospital or sent to Daisy Hill Hospital.

Lots of brilliant diagnostics and so on are carried out there, but we need to sort out the staffing issue in order to make those places really work. Can you imagine how much easier it would be if a child who had fallen could have their wrist X-rayed in Banbridge rather than them being told that they will have to sit for four or six hours in Craigavon? That immediacy is difficult to get.

Sorry, I do not want to be negative — I genuinely do not — because this is the right trajectory, but I am worried that so many things have to fall into place, particularly around GPs and domiciliary care. If we could get domiciliary care worked out, we would free up our hospitals to tackle some of the waiting lists.

Mr Farrar: I do not see that as negative. Those are exactly the right questions, and we ask them of ourselves when considering why this would be different.

Northern Ireland has tried to do it. One of the challenges that we get is, "How is this any different from local commissioning groups (LCGs) or area integrated partnership boards (AIPBs)?". The truth is that we have talked about this for a long time in Northern Ireland. Bengoa and Transforming Your Care talked about it, but it was never executed properly. At the time when it could have been executed properly, there was money to invest in new service areas, but, sadly, at the moment, under our jurisdiction, there is no new money to execute it, and we are having to try to save money. We could be defeated by that, or we could say, "Right. This is the opportunity. We have to do something, because we can't carry on. The rubber has hit the fan — sorry, road". I am mixing my metaphors. [Laughter.]

Taking up your challenge, Diane, the only way to stop our emergency problem with people waiting for care — elective and urgent — is by having community alternatives. The only way that we can create those community alternatives is by moving our current spend from where it is now into community settings, and we have to do that at a manageable pace, because that is currently in the baselines of trusts. If we simply took 2% off them, they would overspend by 2%. We have to shift the services and do exactly what you said: bring the facilities into more local arrangements and make sure that our general practitioners are there. In the South, the cardiologists said that they would like to be based in the community so that they could see people in the community through an in-reach model.

We have to do this, but it is much harder, because we cannot double-run. Why am I confident that we can do it? I am confident because I look at the Nuffield Trust report of 2022, for instance. It looked at the number of excess bed days and asked, "How many people are staying in hospital longer than they should?"; "How many beds do we have in escalation that are not part of the substantial establishment of the hospital — that were put up to help manage winter and never brought down?"; "How many people are waiting to come out?"; and, "What length of stay is in excess of what the patient would need to get the right treatment?". That 2022 survey suggested that £410 million could be released. The English health system is not superior to ours, but, if we did what has been happening in England around this, we could release around £410 million. The trick is knowing how to get enough scale to be able to say, "We will take that block of funding away from what we currently provide in a hospital setting, and that will be available in a community setting". I describe it as fixing an engine whilst the car is running.

We know that people are being admitted to hospital inappropriately and that people who should be at home are staying longer in hospital. We have to release those people. Therefore, we have to be tougher in making decisions and be able to say, "I'm sorry, but hospital is not the right place for you". We have to be bold and courageous around the speed at which we move the diagnostic service, the elective service and outpatient appointments. We do far too many outpatient appointments that could be done closer to people's homes. We have to work with our clinicians; we need our clinicians onside. On that basis, by the way, we are in discussions with GPs about a new GP contract. That is because the current contract does not incentivise GPs to do what we want them to do. We will have to find ways of moving that money around, and, ideally, we will find some investment money to give to GPs to take this on. Some of the services do not rely on GPs. Cathy's area of professional capacity — community pharmacy — could do an awful lot more than it is doing. That would free up GP access and allow GPs to do more work around frailty.

In a way, you have articulated the conundrum. The 2% shift matters, because it is the only time that we have put a financial strategy underneath the commitment to move care.

Mrs Dodds: Will it be 2% of new, additional money —

Mr Farrar: It is extra.

Mrs Dodds: — over and above that which is already provided for services?

Mr Farrar: It will not be new money; it is money that the trusts are spending now. Take our level of Hospital at Home care. What we will count towards our 2% is not what exists now, because that is already funded. However, if a trust expands the number of beds in its Hospital at Home service, we will count that towards the 2%.

Mrs Dodds: Will there be an auditing process to hold trusts accountable and make sure that that 2% is as you described?

Mr Farrar: Yes. We have used the word "auditable". As soon as we get our integrated neighbourhood teams in place, they will put forward their plan for how that 2% will be spent this year, and we will be in a position to hold them to account for delivering that. We can get fixated on the 2%. The 2% matters because it is a concrete figure to aim for. I would love it to be more, because I believe that Northern Ireland would improve the value of its health service in every pound that it spends if more of it was spent in a community setting than in a hospital setting.

Mrs Dodds: I will end on the 2%. If I ran a local hospice, how would I bid for that 2%? How would I access it? How do I get to that 2%? Trusts and trust boards may decide to provide other services. How would I provide more palliative care in the community through the hospice? That, to me, seems a sensible thing to do.

Mr Farrar: I expect that the integrated neighbourhood teams, particularly given that we are asking them to focus on older people's care, of which end-of-life care is a big chunk, will have a conversation with palliative care providers in the independent sector, as well as some of their community services, about what more could be done to expand the opportunity to keep more people at home in the last days of their life than we currently do and about what that would look like. If that is a bid for a building, that will be difficult, because the capital would not allow it. However, can we expand the service by bringing in people who currently work in the hospital or by transferring some of the money that we spend on vacancies and managing our hospital budget to allow that to be released to pay for more of that care in order to expand community services? That is the dialogue that we expect to happen in each neighbourhood.

Not every neighbourhood is the same. It comes back to the challenge of standardisation. A neighbourhood in the middle of Belfast will have different needs and services from a neighbourhood in a rural area. We know that some of the care issues are most challenging in rural areas. There will be a degree of variability. However, what is not at odds with it is, first, the 2% shift that we want to see and, secondly, the priority being older people. That is what we are effectively setting up the neighbourhood teams to do in the first year.

As Cathy said, the policy will provide a longer-term change. It can and should run for many years. The reason why Northern Ireland spends as much on health as England and more than Scotland and Wales but gets poorer health outcomes is that it spends its money in the wrong place. This shift is a way of getting the right people in the right place at the right time, which, we always say, is our real goal. The 2% is a way of putting in place a financial flow change. We are not just saying that we want to do it. We will try to make sure that those resources are spent on service changes and that we can account for them financially.

The Chairperson (Mr McGuigan): We need to move on, so I want to keep the questions and answers fairly focused. I have one point about the 17 INTs before I bring Danny in.

If we are talking £40 million or £50 million in year 1, we are really only talking £2 million to £3 million for each INT.

Mr Farrar: At first, yes.

The Chairperson (Mr McGuigan): OK.

Mr Donnelly: Like other members, I want this to work. I absolutely agree with the direction of travel. In 2016, Bengoa said that we needed to move our services into the community. We have not been able to do that since then, so this is certainly the right thing to do. I am as yet unclear on how it will work, so I was looking forward to today to hearing a bit more about that, and we had a presentation a couple of weeks ago.

We are in crisis. I hear constantly from people who work in healthcare about the pressure in our hospitals. We are in May; we are not in December or January. We had a briefing on Friday that told us that 45 patients who were medically fit were sitting in A&E in Antrim Hospital, while there were 115 medically fit patients in the hospital who could not be discharged. Those 45 patients were being looked after in the unit, unable to go to a ward. I hear from nurses on the wards that the pressure that they are under with corridor care is increasing significantly. Patients with serious conditions are being treated in corridors, with no dignity. That pressure is increasing and putting extra stress on staff. We are in crisis here. I understand that that number increased from 45 patients to around 70 on Tuesday morning, because, obviously, there were few discharges over the bank holiday weekend.

We are in crisis. We need this to work. The bottleneck is clearly at the back door, and, unless we build capacity in the communities for care packages and nursing home placements, we will not reduce that pressure. Do you know how much we need? Do you know the numbers of care packages and nursing home placements that we need at the minute and that we will need in five, 10 and 15 years' time? We know that the numbers of over-60s and over-85s will increase significantly by 2040. The number of 85-year-olds will double by 2040, and we do not have the capacity in our communities at the minute.

Mr Farrar: I do not have the figures with me today, but the strategic planning and performance group (SPPG) has them. The figures are monitored. There are support services to help trusts that are in difficulty, as happened at the bank holiday after the new year. Bank holidays are a particularly difficult time, as you know.

This might sound counter-intuitive, but I want the Committee to think hard about what I am about to say. Hospital staff who are under significant pressure are under pressure because they are dealing with people who, if we had the community services in place, would not necessarily need to be in their care, right? The only way to address that is by finding a way to take money away from the hospital and spend it in a community setting. That might seem counter-intuitive. When I press for a bed or ask, "Can we take down the escalation beds and reinvest the money in a community offer?", that works on the basis that, if you can create the community service, you will affect more than a multiple of one patient. Therefore, that community service affects many people, and it means that we can start to take capacity out of hospital.

We know that the ageing population is growing. Sorry, I should declare my conflict of interest: I am over 65. I know that that will surprise you, but I am. It is a problem that will only get worse if we do not fix it now, because we know that more people will need care later in life. When we decide to admit someone to a hospital, we know the benefits — the patient is close at hand and will get medical treatment — but a lot of that treatment could be provided in community settings. A patient is at risk of deconditioning while they wait in the bed; they are at greater risk of hospital-acquired infection; and, frankly, they will probably not come out with greater outcomes. We need to explain the policy to the public: that it will help them because effectively reducing hospital capacity in the short term will enable us to provide a better community service.

Mr Donnelly: That is exactly what I want to see. I want to see it work, but I am not sure how it will work.

My next question is about the INTs. We have neighbourhood teams based on the GP federation geography. You mentioned that older people's care will be a priority, so you are directing the INTs to prioritise older people's care. You are focusing on that. You are giving them that guidance and direction. Is that correct?

Mr Farrar: We have already done that. We set that out in the publication that came out — when, Cathy?

Professor Harrison: We have prioritised older people, and we have indicated what areas we would like the INTs to start with. That is what we are getting into now in our workshops. We had our first workshop, where we brought everyone together to talk about and socialise the issue more widely. In May and June, we will get into much more of the planning and what you are pushing towards: what will this actually look like? If you are an INT and you are coming together, we will help you to understand who your population is and how it is using your services. We are asking the INTs to focus on older people. We have to define it: we have to say how many older people there are in an INT's area and where they live. We will ask what the INTs will focus on in the short term. We would like to see some short-term work on the model start this year. To begin with, we will ask the INTs when they come together to think about the services that they are already commissioned to provide and have been funded for. From the experience of seeing other neighbourhood models, we know about just getting people into a room and talking with purpose, and a lot of service providers will never have done that before. Even those who work really closely together, such as our GPs and community pharmacists, do not get an opportunity to do that, let alone our social care providers and our GPs. Small changes that will help can be made.

Danny, we will focus on three main areas for the older population. The first is helping people to stay well at home this winter. That will mean, for example, putting a really big focus on our vaccination programme for older people. We can look at last year's data and see how many people were admitted to hospital for the flu. We can focus on that. We must also make the most use of the proactive care models that Diane mentioned, anticipatory prescribing and all the things that we can already do and are already funded to do. We need to work more meaningfully and with purpose to help more people to stay well at home. The second area is helping older people, at-risk people and people who are at end of life to access the care and services that they need in the neighbourhood. We will have a focus on access. We will ask providers, "How can you work together? If someone needs care today, how can they get it in the neighbourhood?". The third area is about how those services can start to work together for their population. We need to think about how those services can work together to get people back home when they are medically fit. We have touched on some of the barriers, but there are other small barriers in the system that accumulate. There are opportunities. We have to start somewhere, and we are focusing on older people this winter through those three areas.

Mr Donnelly: You mentioned end-of-life care: we will discuss palliative care later today. Palliative care is part of the neighbourhood model. A lot of those services are delivered in the community. Will palliative care providers be part of the INTs?

Mr Farrar: Last week, at the first development day, we asked the group, "How can you make sure that organisations that have a contribution to make are not hamstrung by having to find 17 people to sit on the management board every Monday morning in order to discuss what is happening in the community and all the rest of it?". One of the options that we debated that we have not landed on yet but that is under consideration is a bit like the model when the primary care trusts in England had a professional executive committee. There was a group of wider stakeholders who met and talked about the clinical changes that could be made. To go back to the original question, I imagine that, in that scenario, we would include our hospices, independent care providers and other independent healthcare providers such as optometrists. Those stakeholders do not have the ability to support every INT meeting, but they have the ability to bring out guidance to support the 17 INTs. That would be a way of ensuring that our end-of-life care providers can inform the art of the possible and that the INTs understand how they can transform palliative care.

Mr Donnelly: I imagine that palliative care providers will be interested in being involved in that because of the services that they deliver in the community. Were they invited to the development day?

Mr Gearóid Cassidy (Department of Health): The hospices were not specifically invited. There was a focus on the trusts, community services, general practice and community pharmacy. We cast as wide a net as we could for the initial workshop, but the next iteration —.

Mr Donnelly: It was not very wide if you did not invite palliative care.

Mr Farrar: We will apologise for that. There was no reason why we could not have had palliative care providers there, but we will catch them up.

Mr Donnelly: Will you commit to inviting them to future meetings?

Mr Farrar: Yes, of course.

Mr Donnelly: As we have said, they are a key part of the neighbourhood model, and, certainly, they should be involved.

Mr Farrar: As you are aware, I recently gave up a day of my time to look at interesting models of palliative care.

Mr Donnelly: I was coming on to that. It is my next question.

Mr Farrar: End-of-life care accounts for a significant proportion of the spend on older people's care. Brilliant research on that — it has not been published yet, so I will not say too much about it — was carried out by Ulster University, funded by Marie Curie. It looked at care costs in the final year of life and described the total costs. In that research, you can see the real opportunities if we work with the colleagues who are sitting behind me and provide alternatives that will save some of that money and get better patient outcomes, which is the critical thing.

Mr Donnelly: You visited St Francis Hospice in Dublin yesterday with the Chair and me. We talked about its long journey of 20 years to get 100% funding for palliative care services. That was a fantastic achievement down South. What learning did you take away from that visit?

Mr Farrar: I took away a slight disappointment in the sense that I had rather hoped that its business case for change would give us more insights into the value proposition of the cost of care in palliative community settings versus what was provided previously. As you know, the South was able to increase funding for palliative care when it was getting overall growth in its budgets. We do not have that, so we have to argue about where to take resources from to spend them on palliative care. That was slightly disappointing, but, on the other hand — when I was walking around afterwards, I talked about this — the South has a lot of evidence of where its community service model is having a big impact. Given the South's research and evaluation capability, it would be interesting to ask it to evaluate the model that we are trying to develop.

A bit of this afternoon's conversation has been a chicken-and-egg question, when it comes to asking how we will understand it and what will change. As we go through it, we will learn by doing. I will be able to come back to you and say, "If you look at the way that we are advancing our care for older people, you can see what the model will be able to do when it gets to scale". I will be happy to come back, as we go through the year, with practical examples of where those INTs have done things, rather than talking about what we anticipate that they will do. That is when you will start to see it.

I am confident about that because I have looked at other places where it is already happening. The Committee is going to visit London with me. We will look at four things, and, from those, you will get a real sense of what we would like to do in Northern Ireland. Obviously, we will do the Northern Ireland version of them, but that gives me a lot of confidence that we can target the people at risk, avoid hospital admissions and deal with inequalities, which will be the subject of one of the presentations that we will hear. I am confident that we can do that if we can get everybody to believe and trust us. Quite a number of people have asked, "Have we not done this before?", but I do not think that we have done it with the discipline, rigour, thoughtfulness and determination that we have this time. I would love to be back at the Committee in the autumn telling you about the progress that the INTs have made. Hopefully, you will hear us talk not conceptually but practically about what we expect to happen.

Mr Donnelly: Thank you.

Mr Robinson: Thank you, permanent secretary. Like others, I do not think that there is anybody in the community who does not want to see improved services. If that is the direction of travel that we need to go in, we are certainly up for it. We are always up for that challenge, and I am sure that the public will support us in that.

I have a number of questions, but I will pick up on a comment that you made earlier. You said that England does not have a better healthcare system than we do, but, if it is already administering a similar model to this, why are they not the very best? Surely that is not an admission of failure already.

Mr Farrar: I think that my first comment was that, overall, England does not have a better health system than ours. It was a more general comment. I do not think that we can look at England and say that everything there is perfect and that we should adopt everything. That was a general comment.

The other thing is that, if you look at England's approach to neighbourhood — England has been at this for three years and has just issued its guidance — and its model, you see that, although it is there, it is patchy. What we are trying to do, for all the reasons that the Chair challenged us on, is say that this is for the whole of Northern Ireland. I can take you to parts of England where I would say, "That illustrates exactly what we want to do". However, it is covering one primary care network area, which is 50,000 people. Although we can learn from that, I do not think that England's implementation of that policy is ahead of what we are doing, and it is more complicated there than it is here, in that it has three neighbourhood models. We have a fairly simple structure of neighbourhood. England is talking about three different models.

Mr Robinson: OK. If you had a crystal ball, what specific outcomes would you like to see in it for June 2027, when that management board should be in place?

Mr Farrar: June 2026 or June 2027?

Mr Robinson: June 2027. Next year.

Mr Farrar: Well, that is a year ahead. We hope that those management boards — those INTs — will be in place this year. We will have done the first three days of development by the end of the quarter. I think that you will be able to see them in place. I think that their impact will be to help Northern Ireland by looking at more areas, other than just older people's care, where the redesign of services is possible, and we will start to see examples where what you would otherwise have been in hospital for or waiting in hospital for is being accessed directly through community services. You would, effectively, have people being cared for in the community who, today, would have been admitted to hospital.

Mr Robinson: Will any digital systems be required to support integrating that model?

Mr Farrar: There will be, but, in essence, because the Epic platform talks to EMIS, which is the GP platform, we think that it is a question of asking our system to deliver it, rather than investing in new ones. I am really hopeful about something that I will show to the Committee in June. Systems such as Eclipse, which is the one that we will look at, has a record of the entire population and starts to predict, depending on the information that it has, need and people's deterioration. Where it has been used in parts of England, it really helps to target attention on the people who are at greatest risk of hospitalisation. Of course, the data is all there: we know the number of people who have chronic disease and their record of hospital admission over a period. You can start to use that data to target those people. It is more of a software package to support our data platform. Certainly, that would be in our invest-to-save category, because that is exactly what you would need to have.

The other bit of decision-making software is to help our resident doctors and consultants to understand that there is a community alternative in place so that they do not admit by default but can refer to it instead. You can see that in decision-making tools. I have asked Paul Rice, the chief digital information officer (CDIO), to look at some of the most effective of those. I have seen one called "Interpreter" that is really good. It is a decision-making tool that stops you admitting by default, and you have to override it if there is no alternative. We find that resident doctors will admit by default if they do not know that there is an alternative. They do not want to send home someone who looks like they need care, but that perpetuates the admission of people who could have been cared for elsewhere. The decision-making software allows you to say, "I have been through the process, and hospital admission is not required". You would then have to override it to make an admission. It helps the resident doctor, in particular, to say, "I am going to refer you back to your GP", "This is the support line that can help you", "These are the community services available to you " or "Someone will be in touch". It stops that admission by default, which is what happens now. Doctors can start to say, "I do not need to admit you". That is another piece of software. That and Eclipse are two areas that we will look at to help our teams to do their jobs.

Mr Robinson: I appreciate that, Mike. We will certainly look forward to the update in June.

Mr McGrath: Apologies for missing the start of the meeting. I was at the Policing Board, getting in the road.

I will genuinely try not to be cynical, Mike. I have been on the Health Committee for six years, however, and, at this stage, it has been near beaten into me to be cynical, but I will try not to be, as we are genuinely desperate for something different and new to tackle the issues.

There is one issue that you might be able to explain to me that would help with my understanding of the model. If we shift 2% of our funding out of hospitals and into the community, the idea being that we deal with people in the community rather than in hospital, we will still be dealing with the same number of people. How would we deal with the backlog, which is what we MLAs mostly get it in the neck about. I hope that you will say that, for the cost of what is spent on people in the community, you will be able to deal with more people than you would in hospital. The problem is that we have an ageing population: the projections are that more and more people will need services. If, essentially, we just shift from one side of the house to the other, how will that capture more people and deal with backlogs?

Mr Farrar: There is evidence that it is cheaper to provide that service because it gets to people earlier, thereby avoiding excess cost and wasted resource. I feel bad saying "wasted resource" in relation to someone who is waiting to go home, as that is a person, but there are better ways that we could use the money that would also help that person. There would be a multiple benefit, in that we would be providing a service as opposed to the attention being on one individual in one bed.

We focused a lot on the figure of 2%. That is really important because it will bring new resource, but we are already bringing new resource into the community through things such as Macmillan support. AstraZeneca is also supporting us through the recent signing in relation to respiratory care, and we think that we will get some Innovate money to deal with obesity. There is that new money coming in, and, as you will be aware, we also have transformation funding. Our bids for electronic prescribing and dealing with transitions for young people will ultimately be played out when the money is all in our budget that has moved across to the neighbourhood.

I come back to the point that Cathy started with, which is that we are already spending a lot of money. I do not know whether Diane was indicating that she thought that that 2% was for community. We probably spend about 30% to 40% of our total budget in the community already, rather than in hospitals. There is a lot of money that we will be able to spend better by coordinating services. The idea of having a management board for the community resource is that it will look at where we spend our money, what our problems are and provide a list of 30 named people whom we are trying to get out of hospital and the packages of care that should be put in place for them. That is a practical model that takes into account the fact that community nursing and general practice are already doing things and that we have advanced nurse practitioners and the voluntary sector. It would mean that we would literally be coordinating the care, and I think that we will get added value from that. Those are four areas where we will probably get the added value of what we are trying to do. The shift of the resource is one of them, but the others are significant as well.

When we asked people to come forward in response to the call for evidence, we got lots of evidence of things that are already being done but not being done at scale. We could and should do those things more widely.

Mr McGrath: I do not wish to fixate on the 2%, but, if you are to move services from hospitals into the community, will the trusts be subject to further cuts? The trusts have had not just cuts but obliterations over the past years. They have been asked to find £50 million, £60 million or £70 million worth of cuts, which is substantial. If trusts are trying to shift services out the door and deal with a diminished budget, it will be increasingly difficult for their CEOs to find things that they can do differently. If there are savings, is there a way that some of those savings could be delivered back to the trusts to deal with the flow that we need to see through hospitals and help patients who are in EDs?

Mr Farrar: It is hard to have everything.

Mr McGrath: You can give us the shortlist. [Laughter.]

Mr Farrar: We are asking the trusts to make efficiencies. We have to do that because our budget does not cover even last year's pay award, let alone next year's. We have to make efficiencies. The figure that we are looking for at the moment is 6%. Over the three-year period, we hope for a profile of 6%, 3% and 3%, by the end of which, if all goes well, we should be in run rate balance. That will require support from the Executive over and above our allocation. It is difficult for me, as accounting officer, to get to a position to look at balancing budgets without asking for significant reductions and savings. There will be more of that as things crystallise.

The point that we are making is that you save your 6% without making service reductions by investing your 2%. That is the approach that we are taking. If you can avoid the admission, you reduce your need for staff. If you can do enough of that, you can reduce your need for staff, which plays into our vacancies and our premium labour costs, given that we are filling some of our vacancies with additional staff to ensure that we can cover the number of people who are in hospital. The figure is 2% because that starts the process of enabling the trusts to rightsize their financial position, not just their service offer. Without the 2%, it would be incredibly hard for the trusts to start making those efficiencies. Currently, we have escalation beds that go beyond the establishment for which they were commissioned, and they are being paid for by the trusts. We need to move those people away from our hospitals to allow the trusts to release the costs.

What you do with the cost that you save is a political decision. In England, after the quality and outcomes framework was introduced in 2004 for general practice, there was a major dip of about 10% in people with ambulatory sensitive conditions going to hospital. That created capacity in hospitals, but the Government of the time said, "Our priority is to use that capacity to reduce elective waiting times", and they put a profitable tariff against any operation that you did. That is where that cost went to, and, all of a sudden, that capacity was used, but waiting times were reduced from 18 months in 2001 to 18 weeks by 2008. It is a choice. If Northern Ireland is faced with a fiscal challenge, it may choose to say, "We need to take that money out" as opposed to saying, "We'll use that".

We still await confirmation of that, but, at the same time as we are doing this, we are racing ahead with the Programme for Government, which is really about trying to reduce the elective waiting times. We have not forgotten about that. If you really want to get waiting times down permanently, you have to deal with the stock of people, which is what we are doing with the Programme for Government, and the flow of new people. If you just operate on the stock and do nothing about your flow, your number will go up. The neighbourhood scheme is about flow management. The stock is in the Programme for Government.

Mr McGrath: The cynic in me would have asked, "Are you going to invest your 2% in red, black or the horses?", but I am not being a cynic today. Hopefully, that will get it all sorted. We will wait and see.

The Chairperson (Mr McGuigan): That is us. Thank you very much. We appreciate your coming before us and giving us your time.

Just before we allow you to go, I thank you for the visit yesterday to St Francis Hospice. It was very valuable, given the work that the Committee is doing. I hope that you also found it valuable. Thank you for your assistance with the visit to London as well.

We talk a lot here, as we have today, about changing policies and shifts in our health service. We all recognise that those are necessary and hope that they will be successful. The current Minister has indicated that he will not be here in the next mandate. Perhaps unfairly, I will ask you about your position. We want to see leadership driving some of the changes that we need. I do not know whether you have any view on your future.

Mr Farrar: This will be on the public record, so it is a bit tricky, but I can give you the facts. I have contractually agreed that I will be here for the first six months of this financial year. That takes us to September. We are in discussions about extending that to the end of the year. The Health Committee should be interested in what happens beyond the next election. It is about having someone who might be able to do five years so that there is continuity. I would be concerned if I felt that we were embedding a direction of travel only for someone to come in and take it in a different direction. The service is really behind this, and people understand the logic of it. We have done a lot on culture and style, and we feel more like one team. The trusts are with us now. We do not have an "us and them" situation in the same way as we might have had in previous years.

From my perspective, I am definitely here until September and probably until the next election. Beyond that is a question for —.

The Chairperson (Mr McGuigan): That was a very unfair question, but I asked for a specific reason. We need stability and leadership continuity. We will not get that from the ministerial position, but I think —.

Mr Farrar: You should probably ask my colleagues whether they would like that to be the case. [Laughter.]

The Chairperson (Mr McGuigan): Thank you very much for your time.